To address the intergenerational transmission of obesity and diabetes, strategies promoting the health of women of reproductive age appear to be urgently needed. In this narrative review, we ...summarise what has been learned from many prenatal clinical trials, discuss the emerging evidence from preconception clinical trials and highlight persistent gaps and critical future directions. Most trials tested prenatal interventions that resulted in a limited gestational weight gain of ~1 kg and reduced gestational diabetes by 20–30%. These interventions also reduced macrosomia by 20–40% but had little-to-no impact on other offspring outcomes at birth or beyond. Far fewer trials tested preconception interventions, with almost all designed to improve conception or live-birth rates in overweight or obese women with infertility rather than reduce intergenerational risks in diverse populations. Preconception trials have successfully reduced weight by 3–9 kg and improved markers of glucose homeostasis and insulin resistance by the end of the intervention but whether effects were sustained to conception is unclear. Very few studies have reported offspring outcomes at birth and beyond, with no evidence thus far of beneficial effects on offspring obesity or diabetes risks. Further efforts to develop effective and scalable strategies to reduce risk of obesity and diabetes before conception should be prioritised, especially for diverse and under-resourced populations at disparately high risk of obesity and diabetes. Future clinical trials should include interventions with high potential for dissemination, diverse populations, thorough maternal phenotyping from enrolment through to conception and pregnancy, and rigorous assessment of offspring obesity and diabetes risks from birth onwards, including into the third generation.
Graphical abstract
Difficulty achieving preset goals (e.g., ≥5% weight loss, ≥150 min of weekly physical activity) in the yearlong National Diabetes Prevention Program (NDPP) can prompt dropout and diminish benefits. ...We piloted a more patient-centered NDPP adaptation (NDPP-Flex) that promotes a variety of attainable and individually tailored goals to reduce diabetes risks, along with flexibility to adjust goals each week as needed.
Retention, physical activity, weight, and glycated hemoglobin (HbA
) were evaluated among diverse participants with diabetes risks who received our pilot of NDPP-Flex beginning in January and July 2018 (
= 95), with a planned comparison with standard NDPP delivery in preceding cohorts that launched between September 2016 and October 2017 (
= 245). Both the standard NDPP and NDPP-Flex interventions were 1 year in duration and implemented in phases (i.e., nonrandomized).
Average adjusted retention (e.g., 158.90 ± 15.20 vs. 166.71 ± 9.38 days;
= 0.674), physical activity (157.97 ± 11.91 vs. 175.64 ± 7.54 weekly min;
= 0.231), and weight loss (1.46 ± 0.38% vs. 1.90 ± 0.24%;
= 0.396) were similar between NDPP-Flex versus standard NDPP. However, NDPP-Flex participants had greater HbA
reduction on average (0.22 ± 0.05% vs. 0.06 ± 0.03%;
= 0.018) and were more likely to have normoglycemia at follow-up (odds ratio 4.62;
= 0.013 95% CI 1.38-15.50) than participants in the standard NDPP.
An adapted, more patient-centered NDPP that focuses on flexible, self-selected goals may be a promising strategy to improve glycemia even in the absence of substantial weight loss.
The Medicare Diabetes Prevention Program (MDPP) provides unprecedented coverage of a behavior change program for older adult Medicare beneficiaries, but uptake has been extremely limited; only 1.5 ...sites deliver the program per 100,000 beneficiaries nationwide. Inadequate reach and utilization of the MDPP threaten its long-term success; thus, the purpose of this project was to determine facilitators and barriers to MDPP implementation and use in western Pennsylvania.
We conducted a qualitative stakeholder analysis project with suppliers of the MDPP and health care providers.
Using an implementation science framework, we conducted individual interviews with 5 program suppliers and 3 health care providers (N = 8) to determine their perspectives on positive aspects of the program and reasons for MDPP unavailability and lack of use. Data were analyzed using Thorne and colleagues' approach of interpretive description.
Three main themes emerged: (1) facilitators and attributes of the MDPP, (2) barriers to MDPP implementation, and (3) suggestions for improvement. Facilitators of the program included technical support and webinars from Medicare to assist with the application process. Barriers such as financial reimbursement constraints and a lack of a systematic referral process were noted. Stakeholders suggested refinements to participant eligibility and performance-based payments, a seamless method of flagging and referring patients through the electronic health record, and ongoing virtual program delivery options.
Findings from this project can be used to improve implementation of the MDPP in western Pennsylvania, support Medicare policy refinement, and inform implementation research to promote broader adoption of the MDPP across the United States.
Introduction
Intrauterine exposure to maternal obesity and hyperglycemia greatly increases offspring health risks. Scalable lifestyle interventions to lower weight and glycemia prior to conception ...are needed, but have been understudied, especially in diverse and low-income women with disproportionately high risks of negative maternal-child outcomes. The objective of this report is to provide initial evidence of the National Diabetes Prevention Program’s (NDPP) effects on maternal-child outcomes in diverse, low-income women and their offspring.
Methods
The yearlong NDPP was delivered in a safety net healthcare system to 1,569 participants from 2013 to 2019. Using medical records, we evaluated outcomes for women < 40 years who became pregnant and delivered after attending the NDPP for ≥ 1 month (n = 32), as compared to a usual care group of women < 40 years (n = 26) who were initially eligible for the NDPP but were excluded due to pregnancy at enrollment.
Results
Most women in either group were Latinx, had Medicaid or were uninsured, and had obesity at baseline. The mean difference in BMI change from baseline to conception was − 1.8 ± 0.6 kg/m
2
(p = 0.002) for NDPP versus usual care. Fewer NDPP participants had obesity at conception (56.7% vs. 88.0%, p = 0.011) and hyperglycemia in early pregnancy (4.0% vs. 25.0%; p = 0.020) than usual care. No other differences were statistically significant, yet nearly all outcomes favored the NDPP. Covariate-adjusted results were consistent, except the difference in frequency of obesity at conception was no longer significant (p = 0.132).
Discussion
Results provide preliminary evidence that the NDPP may support a reduction in peri-conceptional obesity/diabetes risks among diverse and low-income women.
The Centers for Medicare and Medicaid Services recently issued final rules for the Medicare Diabetes Prevention Program (MDPP), offering an unprecedented opportunity to provide lifestyle intervention ...to Medicare beneficiaries with prediabetes via a pay-for-performance model. The MDPP is based on the widely disseminated, yearlong National Diabetes Prevention Program (NDPP), which has lesser but still beneficial risk-reduction outcomes among minority and low-income participants.
We compare projected payments based on outcomes of a diverse sample of Medicare beneficiaries to service delivery costs, and explore resulting implications for MDPP access and sustainability.
We delivered NDPP in a safety-net health care system from 2013 to 2017 and conducted an analysis of service cost, beneficiary performance, and projected MDPP reimbursement.
Among 1165 total participants, 213 (18.3%) were Medicare beneficiaries. Participating beneficiaries were 40.6% Hispanic, 31.6% non-Hispanic black, and 26.9% non-Hispanic white and 69.5% low-income. Overall beneficiary performance would result in an average reimbursement of $138.52 (interquartile range=162.50). Program delivery costs were $800 per participant, leaving an average gap of $661 per beneficiary.
Findings from delivering the NDPP to diverse and undeserved patients show a large gap between service costs and projected reimbursement. Although many MDPP suppliers are needed to reach all Medicare beneficiaries with prediabetes, insufficient reimbursement may be a deterrent. Health disparities may also widen as suppliers serving diverse and low-income populations will likely receive especially low payments, threatening access. Higher payments are supported by strong return-on-investment findings and seem needed to reduce diabetes prevalence and related disparities.
Reducing obesity and diabetes risks among women of child-bearing age is urgently needed to halt the transgenerational cycle of disease. Interventions among pregnant women have largely been ...ineffective and may be initiated too late to improve maternal and child health. The National Diabetes Prevention Program is a widely disseminated lifestyle intervention that may help mitigate risks before pregnancy. However, the program has targeted relatively older adults, and effectiveness among women of child-bearing age remains largely unknown.
The National Diabetes Prevention Program was delivered in an urban safety net hospital. Reach and effectiveness were evaluated among 4,866 eligible women who were invited to participate in the program. The authors compared enrollment, attendance, and weight loss for women aged 18–39 years as compared to women aged ≥40 years. Data were collected between 2013 and 2016. Analyses were conducted in 2017.
Women of child-bearing age were nearly half as likely to enroll than older women in adjusted models (OR=0.58, 95% CI=0.49, 0.69). Subsequently, younger enrollees were less likely to attend ≥1 session(s) than older women (OR=0.77, 95% CI=0.61, 0.99). There was no significant age group difference in program completion rates or weight-loss outcomes. Both groups lost an average of 3% body weight.
Women of child-bearing age were less likely than older women to engage in the National Diabetes Prevention Program; however, they were equally likely to benefit from weight loss when they attended. Further efforts are needed to improve engagement of women of child-bearing age.
The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show ...potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention.
This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual’s risk, readiness, barriers, and digital competency.
Women with previous gestational diabetes are at high risk of developing Type 2 diabetes. The National Diabetes Prevention Program (NDPP) is a widely disseminated lifestyle intervention to prevent ...Type 2 diabetes. Although NDPP programs are open to adults of any age, participants are usually older adults. Effectiveness among younger women with previous gestational diabetes is largely unknown.
The NDPP was delivered by lifestyle coaches in a large network of Federally Qualified Health Centers. Reach, retention, physical activity, and weight loss outcomes were compared between women aged <40 years with previous gestational diabetes and all other participants. Data were collected from 2013 to 2019 and analyzed in 2022.
Among 2,865 enrollees who agreed to start the yearlong NDPP, 63.3% were Latinx, 18.8% were non-Latinx Black, and 16.4% were non-Latinx White. Younger women with previous gestational diabetes represented <4% (n=107) of participants. There was no significant difference in the frequency of attending ≥1 NDPP session between these women and all other participants (37.4% vs 44.6%; p=0.146). However, among those attending ≥1 session (n=1,265), younger women with previous gestational diabetes attended more (11.27 ± 1.27 vs 8.50 ± 0.22 sessions, p=0.021) and had greater weight loss (3.04% ± 0.59 vs. 1.49% ± 0.11, p=0.010) in covariate-adjusted models than other participants.
Diverse younger women with previous gestational diabetes attending the NDPP had one third greater attendance and twice as much weight loss as other NDPP participants but represented a much smaller proportion of enrollees. Thus, the NDPP appears to be a beneficial but underutilized resource for this high-risk population.
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